Wilderness Expedition Registration Form

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone Number

(###)

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Parent/Guardian Work Phone Number

(###)

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Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant's Full Name

Participant's Birth Date

YYYY

Participant's Age

Participant is:

T-shirt size

How did you hear about BRDC?

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

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Participant's Health Insurance Company

Policy Number

Group Number

Primary Care Physician

First Name

Last Name

Physician Phone Number

(###)

###

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Date of Last Tetanus Shot

Does participant suffer from any medical, physical, emotional, or behavioral conditions which might affect his/her safety while at this event (e.g. claustrophobia, vertigo, asthma, heart condition, diabetes, epilepsy, etc.)?

If yes, please specify:

Is the participant currently undergoing any form of medical or psychological treatment, including medication?

If yes, please specify:

Will the participant be bringing any prescription or nonprescription medication to this event?

If yes, please list medication, does, frequency, and reason for each medication:

Do you autorize the administration of nonprescription medication (i.e. Tylenol, Ibuprofen)?

Please list any nonprescription medication limitations/exceptions (if applicable):

Please list any MEDICATION allergies:

Please list any FOOD allergies or dietary restrictions:

Please list any PLANT allergies:

Please list any INSECT BITE/STING allergies:

Please list any surgeries or serious injuries in the last two years:

Informed Consent, Release Agreement, & Authorization

I understand that participation in BRDC activities involves risk of personal injury, including death, due to physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the activity coordinators. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the codes of conduct. In case of an emergency involving my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child along with the transportation of my child, by ambulance if necessary, to the nearest available medical facility. Medical providers are authorized to disclose protected health information to the adult in charge, event medical staff, event management, and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all activities offered in the program. I further authorize the sharing of the information on this form with any volunteers or professionals who need to know of medical conditions that may require special consideration in conducting activities. With appreciation of the dangers and risks associated with programs and activities, on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against Blue Ridge Discovery Center, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity to the extent allowable by Virginia State Law. I also hereby assign and grant Blue Ridge Discovery Center and their authorized representatives, the right and permission to use and publish the photographic/video/electronic representations and/or sound recordings made of my child at all activities, and I hereby release Blue Ridge Discovery Center, the activity coordinator, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographic/video/electronic representations and/or sound recordings without limitation at the discretion of Blue Ridge Discovery Center, and I specifically waive any right to any compensation I may have for any of the foregoing. Due to the nature of programs and activities, Blue Ridge Discovery Center cannot continually monitor compliance of program participants or any limitation imposed upon them by parents or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a child participant in connection with programs or activities below. I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. I understand the extent & limitations of the insurance coverage as provided by the organization sponsoring the event, and that my medical insurance is primary. I will inform the leaders of the event prior to the event if there is any change in medical circumstances regarding my child between the date signed below and the start of this event. I understand that I am responsible for my child’s actions and will be held financially responsible for any damage done by my child and will pay for any and all repairs incurred by such damage. I give consent for my child to go on Blue Ridge Discovery Center authorized field trips away from premises. I give permission for my child to ride in a vehicle used for event trips or participant transport. Please sign here:

I have read and agree to the statement above

Yes